| NPI | 1750029732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 063354) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH RES.004478) |
| Enumeration Date | 2022-05-20 |
| Last Update Date | 2024-08-13 |